Provider Demographics
NPI:1528320686
Name:TABARES, JORGE L JR (MACOM)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:L
Last Name:TABARES
Suffix:JR
Gender:M
Credentials:MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 303111
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0052
Mailing Address - Country:US
Mailing Address - Phone:619-723-6705
Mailing Address - Fax:
Practice Address - Street 1:2720 BEE CAVES RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5642
Practice Address - Country:US
Practice Address - Phone:619-723-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01343171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist